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Airway Health Assessment

Have you ever been given a CPAP device?
If you have been given one, do you use it every night?
Are you comfortable with your CPAP and satisfied with its use?

If you answered YES to all three of these questions, you are done. Thank you!

If you answered NO to any of these questions, please continue to Parts 1 and 2.

PART 1: Epworth Sleepiness Scale

On your worst day, how likely are you to doze off while doing the following activities?

Please use this scale: 0= Never, 1= Slight, 2= Moderate, 3= High

Check one of the following numbers:

Being a passenger in a motor vehicle for an hour or more
Sitting and talking to someone
Sitting and reading
Watching TV
Sitting inactive in a public place
Lying down to rest in the afternoon
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic


Have you ever been told you snore?
Does snoring cause any problems at home?
If you answered YES, would you like to fix that?
Do you ever wake up choking and/or gasping?
Do you have high blood pressure?
Do you have diabetes?
Have you ever experienced an irregular heart rhythm?
Do you feel fully rested upon waking in the morning?

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.